Exploring Modern Medical Imaging in Forensic Radiology

Respecting the deceased patient and their family is of utmost importance when loved ones are dealing with a loss. The cost of a funeral and other arrangements can be overwhelming, let alone the financial burden of an autopsy report (Beck, 2011) (Higginbotham-Jones & Ward, 2014) (Puranik et al., 2014) (Roberts et al., 2014) (Thayyil et al., 2010). A traditional autopsy exam causes uneasiness, especially for families of religions that dictate specific rituals, such as those of Jewish or Islamic faith, because the families must wait until the dissected body is brought to them to be put to rest (Beck, 2011) (Higginbotham-Jones & Ward, 2014) (Puranik et al., 2014) (Roberts et al., 2014) (Thayyil et al., 2010). With the constant advancement of medical imaging technology in mind, this paper will compare two possible alternatives or additions to a traditional autopsy exam that could provide more information on the deceased body in a less invasive manner.

The benefits that medical imaging brings is an advancement that is irreplaceable, especially when determining the cause of death. Finding out this information is not only important to ease grieving minds, knowing that their loved one may not have suffered, but also to alert the public of potentially growing statistics and frequent patterns to be aware of (Thayyil et al., 2010). It was also validated that performing a thorough autopsy can prevent history from repeating itself in future generations of that family if that information can be obtained. In fact, Beck (2011) highlights the advantages of the digital age, with one of them being that the images can be stored indefinitely, and therefore can be reviewed upon repeatedly. Other conveniences include the rapid delivery of the images, being able to make necessary adjustments, and being able to send them anywhere (Beck, 2011). Higginbotham-Jones and Ward (2014) further explain that an additional advantage of imaging is being able to use the images in legal cases, especially in non-accidental occasions. This is especially important for the identification of a body, the age, or potential foreign artifacts (Higginbotham-Jones & Ward, 2014).

Although imaging in forensic radiology is not a well-established concept, post-mortem magnetic resonance imaging (PMMR) offers valuable information in understanding the cause of death (Higginbotham-Jones & Ward, 2014) (Ruder et al., 2014) (Thayyil et al., 2010). For example, one challenge of post-mortem imaging is the biological changes that occur once death has ensued, such as the collection of fluid due to a loss of circulation (Higginbotham-Jones & Ward, 2014) (Ruder et al., 2014) (Thayyil et al, 2010). Despite this dilemma, a T2 weighted image can be utilized to feature the fluid in a diagnostic manner and provide more insight as to what conditions the patient was dealing with (Ruder et al., 2014). The information from the T2 weighted image could contain information such as blood clots under the skin, bruised bones, physical organ injuries, excess fluid in the brain, and/or loss of blood supply to the heart (Beck, 2011) (Puranik et al., 2014) (Ruder et al., 2014).

To elaborate further on PMMR’s role with the head and brain, Ruder et al. (2014) describes how the imaging is capable of leading to such diagnoses as an example. First, the excess fluid in the brain could be indicative of a blunt force trauma, where the diffusion of water molecules in tissues would be lower. In addition, normal evidence would show a high signal from the basal ganglia and thalamus on another type of weighted image, referred to as T1, and there would be an inadequate amount of cerebrospinal fluid on other imaging parameters (Ruder et al., 2014). These indications suggest that PMMR best accomplishes the diagnosis of traumatic brain injury (Beck, 2011).

While the crucial role that PMMR has with vital organs like the heart and brain validates its use, it does have other areas in which it dominates (Puranik et al., 2014). Abdominal imaging is an area in which contrast is not needed because of PMMR’s ability to highlight soft tissue pathologies, specifically of the organs (Ruder et al., 2014). Using a higher strength MRI scanner, such as a three Tesla, also enhances the quality and precision of the image, especially with a deceased fetus body (Puranik et al., 2014). PMMR can also be used in musculoskeletal imaging, where excess fluid in the bone marrow can be displayed. The benefit of having this knowledge is that fractures can be chronologically determined as either before death or after death, depending on whether fluid is present (Ruder et al., 2014). Because the same information, if not more, is being obtained in a less invasive manner, the benefits of PMMR suggests that it should be used as an alternative to a traditional autopsy exam (Higginbotham-Jones & Ward, 2014) (Puranik et al., 2014) (Ruder et al., 2014).

Despite all the benefits PMMR has to offer, there are some disadvantages that should be made known if there is another modality that can obtain the best information when considering quality and safety. One of the major safety concerns of MRI is ferrous metal, as there is an intense attraction to the equipment’s magnet (Ruder et al., 2014) (Beck, 2011). This is a hazard for not only the deceased patient, but also for the operating staff and the equipment itself (Ruder et al., 2014). Additional drawbacks include the availability and access to MRI, how long a scan can take, and how technologically advanced the equipment is (Ruder et al., 2014) (Puranik et al., 2014). In fact, the intricacy of the images requires a trained eye that can only be detected by experienced professionals (Beck, 2011) (Higginbotham-Jones & Ward, 2014) (Puranik et al., 2014) (Roberts et al., 2012) (Ruder et al., 2014) (Thayyil et al., 2010). If there is an inadequate amount of knowledge of the medical professional reading the image, there is an increased risk of missing information and therefore causing a decrease in accuracy and validity of PMMR (Thayyil et al., 2010).

Unfortunately, the most frequent diagnoses missed are major ones such as “pulmonary embolism, coronary heart disease, pneumonia, and intestinal infarction” (Roberts et al., 2012, p. 140). In addition to these flaws, it is important to be aware of how costly MRI is (Puranik et al., 2014) (Thayyil et al., 2010) (Roberts et al., 2012) (Higginbotham-Jones & Ward, 2014). It is not only an expensive bill for the family of the deceased, but also for the medical facility to make structural accommodations to make it accessible (Puranik et al., 2014). Although it is agreed that MRI is an expensive exam, there are some discrepancies as to how it relates to traditional autopsy assessments. For example, Thayyil et al. (2010) states that a traditional autopsy was significantly more expensive than an exam with MRI, computed tomography (CT), and a needle biopsy. On the other hand, Roberts et al. (2012), and Higginbotham-Jones and Ward (2014) state that MRI is more expensive than a standard autopsy exam. It was alluded that this is however dependent upon the extent to which MRI imaging is used (Higginbotham-Jones & Ward, 2014).

Lastly, in terms of PMMR imaging, the findings are largely dependent on the condition of the body, both inside and outside (Ruder et al., 2014). For example, the bodies of the deceased are usually cooler because there is a loss of circulation, but they are also stored in these lower temperatures for preservative measures. This lower internal body temperature decreases the contrast of the image when looking at fat and muscle, which can be an issue when PMMR is considered useful in examining soft tissues. Other issues include various gases within the deceased body in that it can create an artifact on the image and potentially cover up diagnostic information (Roberts et al., 2012) (Ruder et al., 2014). Similarly, when various components of the body begin to settle, such as in the lungs, pertinent information could be overlooked (Higginbotham-Jones & Ward, 2014) (Ruder et al., 2014). These disadvantages lead Thayyil et al. (2010) to believe that PMMR should not be used as an alternative to traditional autopsy.

Post-mortem computed tomography (PMCT) is another imaging modality that can be utilized, and unlike PMMR, it is more widely used in the world of forensic radiology (Ruder et al., 2014). In fact, Beck (2011) discusses that the continuous advancement and increasing use of CT has led to the development of mobile scanners. This advantage has been especially vital in places of disaster where the access to such technology is extremely limited (Beck, 2011). In addition to this, PMCT can eliminate the major safety concern of PMMR, which is the presence of ferrous material. In fact, it is suggested that a PMCT scan should be completed before any PMMR imaging as a precautionary measure (Ruder et al., 2014). Fortunately, CT technology is more accessible and affordable than PMMR, which is important for grieving families as they deal with the financial burden that compiles with the loss of a loved one (Puranik et al., 2014) (Roberts et al., 2012) (Ruder et al., 2014).

To further highlight the benefits PMCT has to offer, Ruder et al., (2014), and Higginbotham-Jones and Ward (2014) discuss that this technology has the capability to accommodate the weak points of PMMR. For example, they discuss that while gas in the deceased body creates an artifact with MRI, this is not the case of CT. More specifically, PMCT can identify the source of the gas, whether it is due to trauma or body decomposition (Higginbotham-Jones & Ward, 2014). Typically, if a trauma is suspected, gas will be identified in coexistence with the internal organs of the deceased patient, and from there, a trained medical professional can conclude as to if it truly is trauma related or if it is merely just gas from the decomposition process. This is especially crucial when a cause of death is trying to be determined (Higginbotham-Jones & Ward, 2014).

One of the most common evaluated diseases in the deceased is cardiac disease (Puranik et al., 2014) (Roberts et al., 2012) (Ruder et al., 2014). While Ruder et al. (2014) and Thayyil et al. (2010) primarily associate sudden cardiac death with the use of PMMR, others also mention the potential role that PMCT has in diagnosing a heart-related conditions (Beck, 2011) (Puranik et al., 2014) (Roberts et al., 2012). More specifically, Puranik et al. (2014) notably states that CT is an asset in identification of diseases that are both inside and outside of the heart and brain of the deceased. In fact, CT can be used as an additional tool when examining the body’s vessels to enhance the likelihood of confirming a vascular disease (Roberts et al., 2012). The vascular system is visualized with the aid of an injected contrast material before imaging has begun (Higginbotham-Jones & Ward, 2014).

While PMCT has a lot to offer and can assist in areas that PMMR lacks, it also has weaknesses. Like PMMR, it is crucial to have trained medical professionals analyzing the images because their eyes are trained to distinguish pathologies from natural decomposition changes that occurs after death (Beck, 2011) (Higginbotham-Jones & Ward, 2014) (Puranik et al., 2014) (Roberts et al., 2012) (Ruder et al., 2014) (Thayyil et al., 2010). Unfortunately, there is a limited number of studies on post-mortem imaging, which creates an issue of having enough trained professionals to adequately read the images and make diagnoses (Puranik et al., 2014) (Thayyil et al., 2010). Obtaining diagnostic accuracy can be problematic when the studies are small, making the significance of the results difficult to assess (Beck, 2011) (Higginbotham-Jones & Ward, 2014) (Puranik et al., 2014) (Roberts et al., 2012) (Thayyil et al., 2010).

To discuss the disadvantages of CT in terms of the exam itself, Puranik et al. (2014) emphasizes that while this imaging modality has the capability to identify abnormalities inside and outside the heart, it was incapable of recognizing certain pathologies that PMMR picked up. In fact, Beck (2011) further describes examples of these inabilities, such as the failure to discover a tear in the heart and liver, or a rupture of the aorta. These flaws may correlate with the trouble PMCT has in displaying the vessels of the body, in which a contrast agent must be utilized and could potentially be failing to represent all the potential information that is present (Higginbotham-Jones & Ward, 2014). PMCT can also produce artifacts from previous work done on the deceased patient’s teeth, which then impacts the clarity of the image (Beck, 2011) These issues force PMCT’s accuracy to decrease, meaning that there is a lower specificity and sensitivity in comparison to PMMR (Higginbotham-Jones & Ward, 2014) (Puranik et al., 2014) (Ruder et al., 2014) (Thayyil et al., 2010).

Overall, the constant advancement of medical technology, specifically PMMR and PMCT has been shown to offer incredible benefits in the unexplored world of forensic radiology. Not only is the goal to obtain better diagnostic information, but it is also to accommodate the needs of the family or loved ones of the deceased individual. Despite the apparent limitations of PMMR and PMCT, Beck (2011), and Higginbotham-Jones and Ward (2014) suggest that the modalities be used in conjunction with each other. However, the issue with this is having the adequate resources and professionals to be able to utilize both (Roberts et al., 2014). On the other hand, Beck (2011) declares that that imaging should not be used as an alternative to traditional autopsy. While the answer to whether imaging can replace traditional autopsy remains uncertain because future research is needed on a much larger scale, it is still an invaluable tool in the identification of abnormalities in the deceased and should be utilized in its dominant areas.